Case report
A 44-year-old man with a history of occasional melena since childhood
presented to our hospital with a complaint of acute lower GI bleeding.
The physical examination showed no abnormal findings. Laboratory
evaluation revealed decreased hemoglobin (10.4 mg/dl). The patient
underwent esophagogastroduodenoscopy and total colonoscopy. Although
bright red blood was seen with colonoscopy, the source of bleeding was
not identified (Figure 1a, 1b). Furthermore, the source of bleeding was
not found with abdominal contrast-enhanced computed tomography (CT). The
patient was diagnosed with OGIB, and CE was performed subsequently to
examine the small intestine. Normal intestinal fluid was shown by CE,
and it was difficult to identify the source of bleeding (Figure 2a, 2b).
We explained the necessity of performing BAE to the patient, however he
did not consent to BAE at that time. Fortunately, the bleeding stopped
spontaneously. Magnetic resonance imaging in the outpatient department
at follow-up did not identify the source of bleeding. The patient was
prescribed with Rebamipide at the time of follow-up. After 9 months, the
patient presented to our hospital again with lower GI bleeding. Since
detailed testing including CE had already been performed with the
previous bleeding, BAE was the first test performed after obtaining
informed consent. A diverticulum was revealed by BAEĀ in the ileum at the
50cm oral side from the ileocecal valve, and intestinal stricture was
observed near the diverticulum (Figure 3a). It was difficult to traverse
the colonoscope, and the small bowel series with Gastrografin showed the
blind end that corresponds to the diverticulum and the stricture (Figure
3b). Although no active bleeding was observed during the BAE procedure,
there were no other possible sources of bleeding. Therefore, we
diagnosed MD as the source of bleeding, and decided to treat the patient
surgically. The diverticulum was apparent, and segmental small bowel
resection with primary anastomosis was performed (Figure 4a,4b).
Pathology of the surgical specimen showed the true diverticulum with a
small erosion (Figure 4c), and heterotopic gastric mucosa was seen in
the diverticulum; therefore, MD was diagnosed pathologically (Figure
4d). The patient has had no lower GI bleeding since surgery.